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Management of skin and subcutaneous tissue in complex open abdominal wall reconstruction

Abstract

Purpose

Open abdominal wall reconstruction is often a complex endeavor, usually performed on patients with multiple risk factors and co-morbidities.

Methods

In this article, we review soft tissue management techniques that can optimize the skin and subcutaneous tissue, with the goal of reducing surgical-site occurrences.

Results

Regardless of the hernia repair technique used, outcomes can be highly dependent on the appropriate management of the skin and subcutaneous tissue. Indeed, dehiscence and surgical-site infection can jeopardize the entire reconstruction, especially in cases where synthetic mesh might become exposed and/or infected, setting up a “vicious cycle” (Holihan et al. in J Am Coll Surg 221:478–485, 2015).

Conclusion

Multidisciplinary cooperation between the general and plastic surgeon is useful in cases of tenuous blood supply to the abdominal skin, in cases of redundant, marginal or excessive skin, and in cases of deficient skin.

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Author information

Correspondence to J. E. Janis.

Ethics declarations

Conflict of interest

IK declares no conflict of interest. JJ is a consultant for LifeCell, Bard, Daiichi Sankyo, and Pacira. He has received a prior honorarium from KCI. He receives royalties from Thieme Publishing.

Financial disclosure statement

Dr. Janis is a consultant for LifeCell, Bard, Daiichi Sankyo, and Pacira. He has received a prior honorarium from KCI. He receives royalties from Thieme Publishing. Dr. Khansa has no financial disclosures.

Ethical approval

All experiments in this article comply with the current laws of the country in which they were performed.

Research involving human participants and/or animals

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Electronic supplementary material

Below is the link to the electronic supplementary material.

The placement of percutaneous transfascial sutures for wide intraperitoneal mesh fixation. Supplementary material 1 (MP4 22206 kb)

Minimally-invasive anterior components separation performed through a single 5-cm subcutaneous tunnel, preserving vascular perforators to the skin. Supplementary material 2 (MP4 24062 kb)

Tailor-tacking of excessive, undermined or marginal skin to determine the safe amount of skin excision. Supplementary material 3 (MP4 14066 kb)

The Mercedes panniculectomy, a modification of the fleur-de-lis panniculectomy, involves short, non-undermined upper triangular flaps with obtuse tips, and a high T-junction. Supplementary material 4 (MP4 6717 kb)

The placement of central suspension sutures. These sutures are placed after intraperitoneal mesh inset, and before fascial closure. They are placed into each side of the fascia, lateral to the anticipated fascial closure line, and into the midline of the mesh. The sutures are tied after fascial closure. The purpose of these sutures is obliteration of dead space between the intraperitoneal mesh and the fascia, to prevent fluid accumulation that may impair biologic mesh incorporation. Supplementary material 5 (MP4 15608 kb)

“String of pearls, French fry” technique for wound closure. The skin is closed intermittently. Traditional negative pressure wound therapy is applied into the open sections, and incisional negative pressure wound therapy is applied onto the closed sections. Supplementary material 6 (MPG 11752 kb)

The placement of percutaneous transfascial sutures for wide intraperitoneal mesh fixation. Supplementary material 1 (MP4 22206 kb)

Minimally-invasive anterior components separation performed through a single 5-cm subcutaneous tunnel, preserving vascular perforators to the skin. Supplementary material 2 (MP4 24062 kb)

Tailor-tacking of excessive, undermined or marginal skin to determine the safe amount of skin excision. Supplementary material 3 (MP4 14066 kb)

The Mercedes panniculectomy, a modification of the fleur-de-lis panniculectomy, involves short, non-undermined upper triangular flaps with obtuse tips, and a high T-junction. Supplementary material 4 (MP4 6717 kb)

The placement of central suspension sutures. These sutures are placed after intraperitoneal mesh inset, and before fascial closure. They are placed into each side of the fascia, lateral to the anticipated fascial closure line, and into the midline of the mesh. The sutures are tied after fascial closure. The purpose of these sutures is obliteration of dead space between the intraperitoneal mesh and the fascia, to prevent fluid accumulation that may impair biologic mesh incorporation. Supplementary material 5 (MP4 15608 kb)

“String of pearls, French fry” technique for wound closure. The skin is closed intermittently. Traditional negative pressure wound therapy is applied into the open sections, and incisional negative pressure wound therapy is applied onto the closed sections. Supplementary material 6 (MPG 11752 kb)

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Khansa, I., Janis, J.E. Management of skin and subcutaneous tissue in complex open abdominal wall reconstruction. Hernia 22, 293–301 (2018) doi:10.1007/s10029-017-1662-3

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Keywords

  • Abdominal wall reconstruction
  • Perforator preservation
  • Panniculectomy
  • Wound healing
  • Incisional negative pressure wound therapy
  • Progressive tension sutures